Taking care of care workers

In many nursing homes, turnover rates for certified nursing assistants (CNAs) exceed 100 percent, says Industrial and Systems Engineering Professor David Zimmerman. The retention rate for staff at all levels, including registered nurses (RNs) and administrators, is "terrible," he says.

CNAs, also known as direct-care workers, often leave their jobs because they are frustrated they can't do more to provide quality care to residents and are dissatisfied with their work environment, says Zimmerman. "Particularly, they're dissatisfied with the lack of meaningful input into how to care for residents," he says.

With a five-year, $640,000 grant from the Health Resources and Services Administration, Zimmerman is directing a project to implement and evaluate a team-based care model he hopes will increase worker job satisfaction, boost retention rates and improve the quality of care nursing-home staff deliver.

The model will open the lines of communication among nursing-home staff by laying out clear policies and procedures for providing care. A licensed health-care professional — usually an RN — will lead a team and staff at all levels will play key roles. One aspect of the model will provide a systematic way of identifying a change, such as skin breakdown, in a resident's condition. It will enable staff to convey information about a resident's status more efficiently to people who can make decisions about his or her care. In addition, it will provide better mechanisms for making decisions based on changes in residents' health.

"You can think of this as a triaging step," says Zimmerman. "In some cases, the change may be subtle and not considered serious at the moment, so the intervention simply would be increasing the monitoring for that resident. On the other hand, it may be necessary to take some kind of action, and then you need a decision tree." The decision tree provides alternatives, such as undertaking an intervention within the facility or calling an outside medical provider to give care.

As an example, he cites skin conditions, which are common in nursing homes among bedridden residents. If a skin breakdown appears serious, the team may seek attention from an outside medical provider; however, nursing-home staff could resolve a less-serious problem by supplementing residents' diets or turning them more frequently to increase mobility.

Another area the model will address is correctly identifying and appropriately addressing resident behavior issues. "People are in nursing homes for a variety of reasons," says Zimmerman. "The common reason is that they have some type of impairment. It could be physical, it could be cognitive, it could be emotional, it could be clinical. But any one of these kinds of impairments can lead to disorientation or depression or confusion."

Consequently, he says, residents can be physically or verbally aggressive, emotionally abusive, or might behave self-destructively. "We do a fairly good job of identifying that something is happening, but the etiology of that particular change in behavior is oftentimes not investigated very systematically," he says.

Director of the college's Center for Health Systems Research and Analysis (CHSRA), Zimmerman is collaborating with Nursing Professor Barbara Bowers on the project. CHSRA Associate Scientist Allan Stegemann is project director; several CHSRA researchers are part of the project team and the Wisconsin Association of Homes and Services for the Aging is a partner in the project.

Initially, the researchers will develop, refine and test the model's feasibility. "We have to have an instrument that can be filled out by CNAs who don't have a lot of education, so it can't be something that's very sophisticated, but that can systematically get the information to the RN who will be the leader of the team," says Zimmerman. "And then we have to have a way of making sure the team has enough information when it goes through its triaging activities. We'll also want to have a better instrument and process to make sure that medical providers are notified on a timely basis."

To capture a range of social, cultural and ethnic diversity, they will implement the model in two urban and two rural nursing homes. Then the group will monitor the implementation, analyze the model quantitatively and qualitatively, and refine and possibly expand it into other care areas. Eventually, the researchers will transfer responsibility for education concerning the model to another organization but will monitor it and its implementation for two more years.

The model could mitigate the negative effects of a staff member's leaving, says Zimmerman. "One of the reasons care workers leave is frustration over the lack of some kind of consistent, systematic way of providing care — and therefore not providing quality care," he says. "The ones who remain can carry on in a more consistent fashion because they have a set of consistent policies and procedures." And staff easily can train new workers because everyone understands the same protocols. Ultimately, he says, residents will receive better care.